Voluntary sector specialist service provision and commissioning for victim-survivors of sexual violence: results from two national surveys in England

Abstract Background In England, voluntary sector specialist (VSS) services are central to supporting victim-survivors of sexual violence (SV). However, empirical evidence is lacking about the scope, range and effectiveness of VSS provision for SV in England. Objectives To undertake national surveys to map SV VSS service provision and describe arrangements for funding and commissioning. Design Cross-sectional surveys. Setting VSS services for SV and commissioners from multiple organisations across England (January–June 2021). Methods Senior staff working in VSS services and commissioners from multiple organisations were surveyed electronically. Surveys explored SV service commissioning, funding and delivery, partnerships between organisations, perceived unmet need for services, and views about facilitators and challenges. Data were analysed descriptively to characterise VSS service provision for SV and commissioning across England. Results 54 responses were received from VSS providers and 34 from commissioners. Data demonstrated a complex and evolving funding and commissioning landscape in which providers typically secured funding from multiple sources, impacting consistency and scope of service provision. It was common for multiple organisations to co-commission services, demonstrating trends towards larger contracts that may disadvantage smaller specialist providers. Numerous examples of partnership working between organisations were identified, although developing partnerships was noted as challenging, particularly between VSS organisations. There was clear evidence of unmet need for services, with some groups of victim-survivors such as those from black and minority ethnic groups, often underserved by specialist services. However, there was also evidence of innovative service development and commissioning approaches to meet the needs of victim-survivors who face challenges accessing services. Conclusions This study provides novel insights into SV service provision and commissioning in England, including unmet needs among victim-survivors.


Introduction
The voluntary sector provides a range of specialist services to survivors of sexual violence, many of which have evolved from grass roots organisations responding to unmet local needs.However, the evidence base is poor in terms of what services are provided to which groups of survivors, how voluntary sector specialist (VSS) services are organised and delivered and how they are commissioned.This will be the first national study on the role of the voluntary sector in supporting survivors in England.
Methods and analysis This study uses an explanatory sequential naturalistic mixed-methods design with two stages.For stage 1, two national surveys of providers' and commissioners' views on designing and delivering VSS services will facilitate detailed mapping of service provision and commissioning in order to create a taxonomy of VSS services.Variations in the national picture will then be explored in stage 2 through four in-depth, qualitative case studies using the critical incident technique to explain the observed variations and understand the key contextual factors which influence service provision.Drawing on theory about the distinctive service contribution of the voluntary sector, survivors will be involved as coresearchers and will play a central role in data collection and interpretation.Ethics and dissemination Ethical approval has been granted by the University of Birmingham research ethics committee for stage 1 of the project.In line with the sequential and co-produced study design, further applications for ethical review will be made in due course.Dissemination activities will include case study and end-of-project workshops; good practice guides; a policy briefing; project report; bitesize findings; webinars; academic articles and conference presentations.The project will generate evidence about what survivors want from and value about services and new understanding about how VSS services should be commissioned and provided to support survivors to thrive in the long term.
bACkground Sexual violence is one of the most pervasive forms of violence that deprives women, men and children of their dignity and violates their human rights. 1 Sexual violence most often occurs in the context of familial and intimate partner relationships and co-occurs with other forms of abusive, controlling and violent behaviour. 2In 2017/2018, 150 732 sexual offences were reported to police in England, a 24% increase on the previous year and the highest figure since records began, 3

Open access
being reported to official authorities.Just over one-third of those offences were for rape. 3These numbers do not include sexual violence perpetrated against children and older people.Survivors of sexual violence can and do recover, however, there can be multiple, long-term effects on health, well-being and social life.In England, the cost of sexual violence is estimated to be over £8 billion a year and the cost of each rape is £96 000. 4 Rates of posttraumatic stress disorder are highest for sexual violence compared with all other traumatic events. 5Depression, anxiety, suicide, self-harm, alcohol/drug abuse and sexually transmitted infection rates are all high 6 7 and impacts on mortality have been found. 8Survivors report adverse effects on relationships with partners, family and friends and on their confidence/ability to work 9 and participate in social/community life.Given current and projected rises in sexual violence 10 and the cost to survivors and society if needs go unmet, there is a critical need for high-quality research about the nature and availability of specialist support services for survivors.This protocol outlines a study that will address this need.
national policy and commissioning landscape Historically, the voluntary sector has played a key role in providing specialist services to survivors of sexual violence.In the last decade, there has been increasing national recognition that voluntary sector sepcialist (VSS) services are essential in providing crisis and longer-term support, enabling survivors to recover their confidence and thrive in the longer term. 4 11-14Although services vary from area to area, they often include: crisis and longer-term counselling/therapy; telephone helplines; face-to-face advice; ; play therapy for children; practical support in accessing other services; and, support groups and social activities.
As a result of changes to the structure and funding of health 15 and criminal justice systems in England, the funding and commissioning of services for survivors has become increasingly complex (and devolved) over the past decade.Funding for VSS services comes from charitable trusts and local and national statutory sources, via health, local authorities and criminal justice organisations.This creates a dynamic network of responsibilities at the local level, which requires a high degree of collaboration between commissioners and providers. 10Complex commissioning arrangements also create challenges for providers in ensuring there are integrated, multidisciplinary care pathways for survivors.
One consequence of the recent drive to create a predominately free market model of commissioning is that the continued operation of some smaller organisations, who are adept at meeting the needs of specific groups at the local level, is increasingly under threat. 16n other areas, VSS providers are taking the initiative and collaborating between themselves, moving to common standards and seeking to join up services locally.Commissioners in turn are looking for an evidence to support these new approaches. 10 13 17However, little is known about their effectiveness and how they affect the quality and nature of support for survivors.

Evidence base for the value of Vss services for survivors
There is little empirical evidence about the scope, range and effectiveness of VSS provision, or what survivors value and want from services.There is no systematic review evidence and systematic searches undertaken during the design and development of this study found no largescale, representative evidence.Studies use qualitative methods and typically draw on 'small' participant pools.The exceptions are one national survey with 395 adult survivors of child sexual abuse 18 and evidence from 172 survivors of child sexual abuse submitted to the Independent Inquiry into Child Sexual Abuse. 19Survivors typically want timely, locally available services, a choice of therapy and long-term support from agencies taking a joined-up approach. 19They want to feel listened to, believed and respected, 18 and the independence of VSS services from statutory services is seen as a key benefit. 20Counselling and psychotherapy are often cited as the most helpful services but waiting lists are often long and commissioned therapy may be time-limited. 18Many survivors need and use VSS services over many years. 18udy AIMs And objECtIVEs This protocol reports a mixed-methods study involving survivors as co-researchers.The primary aims of the study are to: 1. Develop a comprehensive national profile of VSS services for survivors in England, giving voice to survivors' experiences and views.2. Perform a comparative analysis of the range, scope and funding of services, survivors' service experiences, service models and approaches, service linkages and commissioning arrangements, in order to make policy and practice recommendations to strengthen the service response to survivors.

MEthods And AnAlysIs study design
The study uses an explanatory sequential naturalistic mixed-methods design 21 with two stages.In stage 1, two national surveys of providers' and commissioners' views on designing and delivering VSS services will allow detailed mapping of service provision and commissioning in order to create a taxonomy of VSS services.Variations in the national picture will then be explored in stage 2 through four in-depth, qualitative case studies that will use the critical incident technique 22 to explain the observed variations and understand the key contextual factors which influence service provision.Data in stage 2 will be collected via interviews with survivors and VSS staff and through documentary analysis.Figure 1 provides an overview of the study stages.

Open access
Figure 1 Study overview.VSS, voluntary sector specialist.

Patient and public involvement
Survivors' views informed this study from its inception and survivors are members of the study research team and study advisory group.Survivors will play a key role in the study's delivery and dissemination, providing critical, experiential knowledge about (some) survivors' needs and practical advice about engaging with survivors' networks and organisations.A VSS service will provide sensitisation training to all members of the research team at the onset of the study.Four survivor co-researchers will be recruited to the study team.Co-research is a participatory and empowering methodology which will: amplify the voices of survivors; enhance the collection of meaningful data; empower survivors participating in the research; and promote learning and development of new skills. 23 24o-researchers will contribute to devising publicity and sensitive approaches to survivor recruitment and materials.Co-researchers will also advise on anxieties survivors may have in taking part in the study and how to address them.During stage 2, the co-researchers will carry out interviews with survivor participants alongside a member of the academic research team.The co-researchers will be trained and supported to develop skills in qualitative research methods and ethical issues.They will also be supported, through a process of supervision and peer debriefing, to identify and address their needs when working with survivors (as research participants).

theoretical orientation
The study is informed by Billis and Glennerster's theory that the voluntary sector has unique features that give it a comparative advantage in the provision of human services compared with the statutory sector. 25 These features include: flatter organisational structures with less distance and distinction between senior or decision-making staff and those on the front line; closeness to communities and being mission-led and driven by core values and purpose.By using this theory to underpin data collection and interpretation, the study will purposefully explore the nature of these distinctive features of voluntary organisations and their effect on the support provided to survivors.stAgE 1: nAtIonAl ProVIdEr And CoMMIssIonEr surVEys In-depth surveys can explore aspects of a situation, seek explanations and provide data to test hypotheses. 26These are important attributes for this study, which aims to map and explore national provision and commissioning arrangements for VSS services.Stage 1 involves the stage 1A: survey development Development of the provider and commissioner surveys will draw on the literature along with findings from 10 to 12 stakeholder telephone interviews and five focus groups, three for survivors and two for staff.

Participants and recruitment
Sexual violence survivors: Three survivor focus groups will be carried out, each comprising 6-10 participants drawn from diverse backgrounds in terms of age, gender, ethnicity and sexual orientation.Two focus groups will include adult participants (one for females only and one for males only).To ensure that young people's views can shape survey development, the third focus group will include 16/17 year olds.Focus groups will be facilitated and coordinated by two VSS survivor organisations, who will identify potentially eligible survivors and distribute recruitment packs.Packs will include a participant information sheet (PIS), consent form and contact details for the research team.Recipients will have at least two weeks to consider participation before being contacted by the research team.
Senior providers and commissioners: 10-12 telephone interviews will be undertaken with national policy and commissioning leaders, along with two focus groups (8-12 participants per group) with senior staff involved in the provision and commissioning of sexual violence services: one in the north of England and one in the south/midlands.Although telephone interviews lack facial and body language cues, they can still produce rich data and can offer participants a more convenient way of taking part in research: this was an important consideration given the participant population of senior providers/commissioners.Participants must be currently in post or have been in post within the previous 12 months and will be invited through the study's advisory group, co-applicant team and recruited using social media strategies.Participants will be drawn from: VSS services, statutory services (eg, mental health, sexual health, drug and alcohol services) and commissioners of sexual violence VSS services from clinical commissioning groups, NHS England, local authorities and police and crime commissioners.

Methods and analysis
Focus groups: Focus groups produce rich, complex data about points of comparison, contrast and consensus between members of a group. 27 28For the three survivor focus groups, a semi-structured topic guide will facilitate discussions.It will be used to explore survivors' views of: (1) their use of VSS services, (2) what they valued about these services, (3) why they might have chosen not to use some services, (4) how services could be improved and (5) ideas about topics to include in the surveys.The topic guide for the senior staff focus groups and telephone interviews will explore participants' views of: (1) the scope and nature of current VSS provision for survivors, (2) referral patterns, (3) service linkages, (4) commissioning arrangements and (5) topics to include in the surveys.The focus group and telephone interview data will be analysed and synthesised using a thematic analysis approach, as characterised by Braun and Clarke. 29age 1b: provider and commissioner surveys Participants and recruitment There will be no sampling, with surveys sent electronically to the following groups: 1. Providers (n=500): VSS service providers; Sexual Assault Referral Centre (SARC) managers; mental health NHS trusts; sexual health services, and NHS alcohol and drug services.2. Commissioners (n=400): clinical commissioning groups (CCGs), local authority directors of public health; regional specialist health commissioners and police and crime commissioners.Surveys will be distributed through our co-applicant and advisory groups' networks.Additionally, we will purposefully target national VSS and statutory organisations, using snowballing techniques to increase response rates.Recipients will be asked to forward the survey URL link to organisations in their local area by email or via professional accounts on social media platforms such as Twitter, Facebook and Instagram.To maximise response rates (target 30%+), reminder emails will be sent 2-3 weeks after the initial survey request; telephone calls will target under-represented organisations or geographical areas and additional publicity will be sent via professional networks.

Methods and analysis
Surveys will be piloted in the West Midlands with 2-3 staff from VSS services and two-three commissioners from health, local authority or criminal justice.Both the provider and commissioner surveys will pursue the same lines of enquiry but with slightly different emphasis and wording of questions, in order to be of maximum relevance to their respective audiences (see box 1).Surveys will be concise and easy to fill in, with a mix of tick-box and free-text responses, taking about 20 minutes to complete.Because computer access may be limited in some of the smaller VSS organisations, paper surveys will be provided on request.
Surveys will be analysed descriptively to map patterns of VSS service provision across England.The analysis will identify key features of VSS services which are most variable across the country, to inform the development of the taxonomy of service provision and commissioning, which in turn will aid case study site selection.The views of respondents about the adequacy of services, possible improvements, and how commissioning is working will also be analysed descriptively, looking for differences and commonalities by stakeholder group (eg, comparing commissioners with providers or VSS providers with statutory providers).The analysis will also identify key issues which merit further exploration through the case studies.
stAgE 2: CAsE studIEs Stage 2 will build on the survey findings and use in-depth case study methods 30 to explore how VSS services are provided and commissioned and the value and benefits survivors derive from these services.The case study work will include detailed analysis of VSS services in four geographical areas using a range of qualitative methods including: documentary analysis and interviews with VSS staff, staff working in the statutory sector, commissioners and survivors.

Site selection
The four study sites will be defined geographically by city or county boundaries, or groups of neighbouring districts.All VSS services for survivors located within that geographical boundary will be included, along with relevant statutory services.Site selection will be based on a realist approach to sampling, 31 designed to generate information-rich cases, which can be compared strategically on variables which combine theory with real-world experience.A two-tier purposive sampling framework will, therefore, be used, using key variables identified from the national surveys.Tier 1 will relate to service provision and commissioning and a maximum diversity sample of sites will be selected using the taxonomies developed in stage 1.Tier 2 will relate to location, with sites selected for maximum geographical spread across England and on the basis of population density (urban/ rural), demography (disadvantaged/affluent/mixed) and diversity (high/low black and minority ethnic populations).Once selected, each site will have a site reference group, led by a member of the research team.Representatives will be invited to take part from VSS organisations, SARCs, statutory services and commissioners from criminal justice, local authorities and health.

Participants and recruitment: staff interviews
There will be interviews with 17-19 staff per site, (68-76 in total across the four sites), including staff in senior and front-line roles, who may or may not have completed a stage 1 survey.Participants will also include frontline workers and/or managers/team leaders from: VSS services; SARCs; mental health services; alcohol and drug services; sexual health services, CCGs and specialised service commissioners; local authority commissioners and police and crime commissioners.Potential participants will be identified in consultation with each site reference group.They will be sent an information pack, which will include: a PIS, consent form and contact details for the study team.Potential participants will be given at least 2 weeks to review the information before the study team make contact to ask if they would like to participate in an interview.Interviews will take place at participants' places of work or by telephone.The interviewers will be mindful that staff participants may also be survivors of sexual violence and will have information about local support services, should any participant require this.
Participants and recruitment: survivor interviews Between 6-12 interviews will be undertaken with survivors across each site.Most interviews will be with survivors who have used VSS services in the past three years, so that experiences and views relate to recent/current service provision and are of maximum relevance (see table 1 for inclusion/exclusion criteria).Potential survivor participants will be sent an information pack, including: a PIS, consent form and contact details for the study team.It may be appropriate for local organisations to approach survivors who they think may be interested in taking part.This approach to recruitment will be supplemented with publicity going out through national organisations and local networks of professional and survivor-led fora.A variety of media will be used including leaflets, newsletters, emails and social media.Twitter and Facebook will be used as they have been found to be particularly effective for recruiting hard-to-reach groups. 32Survivors interested in taking part will be able to contact the research team directly, on a secure dedicated mobile number, by post, email or on a confidential section of the study's website.They will be asked how and when they want to be contacted, in order that they cannot be identified incidentally.Some survivors may prefer to contact the team via a friend or member of staff they already know.
It is anticipated that most participants will elect to carry out the interviews at home because this is likely to be a Open access box 2 semi-structured topic guide for survivor interviews ► What survivors felt they needed following the incident of sexual violence.► Which VSS organisations survivors have made use of.► Why specific services were usedand for how long.► Which services were not used and why; and why one service was chosen over another.► What differences there are in the ways VSS services have been provided.► What values, benefits and limits are associated with VSS services, for themselves and their families/friends.► What are the most and least helpful ways in which services were provided.► What gaps or overlaps there are in local services for survivors.► How services could be improved.more comfortable and convenient location than community venues; however, decisions about location will be made on case-by-case basis.Survivors can choose to have someone with them in the interview for support.Interviews will last between 30 and 60 min and will be audio recorded.A choice of male/female interviewer and co-researcher will be offered.As most survivors' experiences of sexual violence will be by male perpetrators, there will be more female than male interviewers available.An interpreter will be provided for survivors whose first spoken language is not English.Participants aged 16-17 years old will be invited to have a parent/carer or other appropriate adult (eg, support or social worker) with them when meeting with a member of the research team and taking part in an interview.For young people aged 13-15 years, the decision about participation will be made jointly between the young person, a parent/carer and the VSS staff member who knows them best.Young people aged 13-15 years must be in current receipt of VSS services at the time of interview.Fraser guidelines 33 will be used to support the process of assessing young people's capacity to consent.

Methods and analysis
Documentary analysis Documentary analysis will proceed alongside qualitative data collection so that points identified from documents can be explored in staff interviews.VSS and statutory service documents, such as commissioning plans, tender and service specifications, provider service publicity, referral pathways, staff profiles and outcome/performance data, will be analysed.

Provider and commissioner interviews
Staff interviews will be semi-structured and will be either face to face or over the telephone.An initial topic guide will be developed based on stage 1 results and will be piloted with two commissioners and two providers to ensure question validity.

Survivor interviews
Survivor interviews will be informal and will use the critical incident technique. 22This asks participants to recount experiences rather than talk in general or abstract terms. 34A narrative approach will encourage people to tell their stories about their service use, 35 using a small number of open-ended stimulus questions.The narrative section of the interview will be followed by a second, semi-structured stage 36 incorporating questions relating to researcher-defined lines of enquiry which have not already been covered by the participants (see box 2).Survivors will also be asked about why they have not taken up other VSS services on offer locally, why they chose one service over another, and how the ways in which services are provided might make services more or less acceptable to other survivors.Although the focus of the interviews is on survivors' views and experiences of specialist services, survivors (who may also be staff) may discuss topics that they experience as emotive or distressing.The researchers will follow the principles of the McCosker et al distress protocol to guide how they identify and respond to participants' distress or discomfort. 37ta analysis Documents will be analysed using conventional content analysis. 38Staff and survivor interviews will be recorded digitally and professionally transcribed, with transcripts checked against audio files for accuracy.Coding and analysis will use NVivo software.Survivor interview data will be analysed using an inductive classification system designed for critical incident data. 22Although the analysis will be primarily data led and inductive, 39 additional analysis will compare survivors' views about the value of services against the principles of trauma-informed care. 40The Open access same analytical processes will be undertaken for a site-bysite analysis of the staff interviews, using thematic analysis 29 and sub-group analysis by professional role where appropriate.Data from the staff and survivor interviews, and the documentary analysis will then be combined, building a detailed picture of each site.We will draw on Billis and Glennerster's theory of the distinctiveness of human service voluntary sector provision to inform our analysis.
A preliminary cross-site analysis will use a matrix to compare themes across sites and groups (survivors, staff and commissioners).This will triangulate themes from multiple sources; assess the frequency with which themes occur across sites; explore patterns and plausible explanations; and identify themes with the greatest explanatory power.The context, facilitators and barriers to VSS service delivery and commissioning will also be explored.
dAtA IntEgrAtIon Qualitative and quantitative data will be integrated from all stages in order to establish key themes and concepts; identify different configurations and patterns of service provision; and, explore survivors' experiences of these services.Triangulation methodology originally developed for analysing mixed-methods results from clinical trials will be used. 41This will involve: 1. Methodological triangulation, comparing data using different methods, for example, comparing survivors' experiences using data from focus groups and interviews.2. Data triangulation, comparing quantitative with qualitative data, for example, comparing quantitative results about service provision and commissioning from the quantitative surveys with the qualitative case study interviews.3. Investigator triangulation, comparing the analysis of the same data by different team members, including different interpretations from individual academics and co-researchers.Key findings in the form of short written statements from the separate analysis of each dataset will be discussed; integrated into a matrix; triangulated by members of the research team individually; then, using different categories of agreement, collectively shared and discussed by the research team.

dIssEMInAtIon Ethical issues and governance
In line with the sequential and co-produced study design, further ethical approvals will be sought from the Health Research Authority and relevant local authority and police and crime commissioner ethical review boards as the study progresses.
Principal ethical issues include: ► Identifying and responding to the practical, emotional and social needs of participants (particularly survivors), so that research engagement is a meaningful, informed and positive experience.► Identifying and responding to the individual needs of the team's survivor co-researchers and co-applicants, including reducing the risk of re-traumatisation or 'over-involvement'.► Ensuring the confidentiality and anonymity of participants' data and its safe storage, in line with best practice principles of data protection and archiving.
dissemination and expected outputs Dissemination activities will include an interim written report and workshop reporting the national survey results.End-of-study activities include case study site workshops; regional workshops; good practice guides; a policy briefing; project report; bitesize findings; webinars; academic articles and conference presentations.
dIsCussIon This study will generate evidence about what survivors want from and value about services and how VSS services should be commissioned and provided to support survivors to thrive in the long term.Commissioners and providers will be able to compare their local services against the national picture in order to configure services optimally.In the longer term, improvements in survivors' well-being should lead to reductions in service demands.
Protected by copyright.on December 18, 2019 at Barnes Library Medical School.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2019-035739 on 17 December 2019.Downloaded from Open access development (stage 1a) and dissemination (stage 1b) of national surveys for VSS providers and commissioners.
despite most sexual offences still not strengths and limitations of this study ► This will be the first national study on the role of the voluntary sector in supporting survivors, addressing an important gap in current evidence about what survivors want and value from voluntary sector specialist (VSS) services, how VSS and public sector services link together and how VSS services are commissioned.► The study's explanatory, sequential naturalistic mixed-methods design will generate robust, nuanced data about VSS services for survivors.The findings will support local agencies to deliver national policy on providing lifelong support to survivors of sexual violence.► Survivors' views and needs foreground this study.Survivors play a critical role in the design, development and delivery of the study as co-researchers, advisors and co-applicants.► Analysis of the four case study sites will produce rich but context-specific, non-generalisable data about the provision and commissioning of VSSservices for survivors.Protected by copyright.on December 18, 2019 at Barnes Library Medical School.http://bmjopen.bmj.com/BMJ Open: first published as 10.1136/bmjopen-2019-035739 on 17 December 2019.Downloaded from How sexual violence is defined, principles underpinning service provision (eg, feminism or trauma-informed care), therapy models used and priority groups for service provision.► Perceptions of what survivors want and need from VSS services, the benefits they derive and views about the value survivors put on VSS provision compared with statutory provision.Referral patterns and pathways, how VSS services fit with each other and statutory services.► How services respond to diverse population needs, unmet needs or service overlaps.► Sources of funding and trends in funding over the past 5 years, including how funding pressures have been addressed locally and impacts on VSS provision.► Factors influencing the pattern of local services for survivors in last 5 years.

Table 1
Inclusion and exclusion criteria for survivor interviews